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VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
WA2025-12-17

Inquest into the Death of Jamie Frederick GINN

50y · Male·cocaine toxicity

A 50-year-old male died from cocaine toxicity at Perth Watch House after ingesting a fatal amount of cocaine prior to arrest. Although the cause is clear, the manner of ingestion (before arrest versus after detention) co…

toxicologyforensic medicinesystemsupervisioncocaine
TAShome2025-12-11

Coroner's Finding: de-identified SH

57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…

A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…

general practicepharmacologymedicationmethadone
TAShome2025-12-02

Coroner's Finding: de-identified DQ

54y · Female·mixed drug toxicity (methadone and diazepam)

A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…

general practicepharmacologydiagnosticmedicationmethadone
TAScommunity2022-09-29

Coroner's Finding: Eirth, Rebecca Jayne

32y · Female·Combined drug (alprazolam and methadone) toxicity

Rebecca Jayne Eirth, 32, died from combined alprazolam and methadone toxicity following injection of illicit drugs at her supported housing residence. She had a longstanding history of substance use disorder, commencing …

addiction medicinepharmacologyalprazolam
VIC2022-09-29

Finding into death of Mark Skidmore

44y · Male·Unascertained

Mark Skidmore, a 44-year-old man, died in Port Phillip Prison on 14 February 2017. Post-mortem examination revealed multiple prescribed drugs (methadone, mirtazapine, pregabalin) and unprescribed drugs (clonazepam, trama…

forensic medicinetoxicologycommunicationsystemmethadone
NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …

general practiceemergency medicinemedicationcommunicationmethadone
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…

paediatricsemergency medicinesystemmedicationfurosemide
WAhome2021-04-16

Inquest into the Death of Child LDW (Name Subject to Suppression Order)

3y · Female·tramadol toxicity

A 3-year-old girl in state care died from tramadol toxicity after accessing prescribed opioid medication left unsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance ab…

paediatricsforensic medicinesystemdelaytramadol
NSWcommunity2021-01-29

Inquest into the death of Deborah Spencer

56y · Female·Blunt head injury, with hyoid bone fracture being a significant condition contri…

Deborah Spencer, a 56-year-old woman with a history of heavy alcohol use and previous falls, died from blunt head injury with hyoid bone fracture. She was found unconscious near Lemongrove Bridge in Penrith on 22 May 201…

emergency medicineintensive care
WAcommunity2019-11-22

Inquest into the Death of Aaron Stephen MARSH

Male·Multiple injuries sustained in motorcycle crash

Aaron Stephen Marsh died from multiple injuries sustained when he lost control of his unregistered motorcycle and crashed on the off-ramp to Great Eastern Highway while fleeing from police. Police had attempted to interc…

emergency medicineforensic medicinemethamphetamine
NSWmental health2019-10-25

Inquest into the death of T V

23y · Female·Arrhythmia of unknown aetiology

TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…

psychiatrycardiologyhaloperidol
WAcommunity2019-06-26

Inquest into the Death of Frederick John COLLARD

35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…

A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine use and alcohol consumption. H…

cardiologyemergency medicinemethamphetamine
QLDcommunity2019-06-10

Coolwell, Shaun Charles

33y · Male·cardiorespiratory arrest during restraint, involving a predisposition to cardiac…

33-year-old Indigenous man died following police restraint and inappropriate midazolam administration during an acute drug-induced behavioural disturbance. Mr Coolwell sustained injuries while in acute methamphetamine-in…

emergency medicinepharmacologydiagnosticcommunicationmethamphetamine
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
NSWcommunity2019-03-01

Inquest into the death of DB, JD, DC, RG, AH, AB

multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)

This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…

addiction medicinegeneral practicesystemdelayheroin
SAhospital2018-06-01

Coroner's Finding: MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol - Ruling

Unknown·Acute myeloid leukaemia (AML)

Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of…

haematologypharmacologymedicationsystemcytarabine
WAhospital2018-03-22

Inquest into the Death of Steven John COLLOFF

47y · Male·Organ failure following use of synthetic cannabinoids and consequent hyperthermi…

A 47-year-old man died from organ failure following synthetic cannabinoid use and consequent heat stroke. After smoking synthetic cannabinoids (AB-CHMINACA and 5F-AMB), he became confused and dehydrated in a hot environm…

toxicologyintensive careab-chminaca
QLDhome2017-12-14

Robertson, Charlie Mark John

19y · Male·Toxic effects of multiple drugs, primarily gammahydroxybutyric acid (GHB), causi…

Charlie Robertson, a 19-year-old university student, died from polydrug toxicity (cocaine, MDMA, and GHB) on 13 June 2015. During the early morning execution of a police search warrant at his home, seven Queensland Polic…

forensic medicinetoxicologydiagnosticcommunicationgammahydroxybutyric acid
QLDcommunity2017-09-14

John, Timothy

22y · Male·Hanging

Timothy John, age 22, died by hanging 8 days after commencing varenicline (Champix) for smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted suicide. His GP, Dr…

general practicepsychiatrydiagnosticcommunicationvarenicline

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